Republic of the Philippines)

City of ________________)S.S.

BEFORE ME, a Notary Public in the City of __________________, personally appeared

____________________ with his Community Tax Certificate No. _________________ issued
at _________________ on ___________________, known to me and to me known to be the
same persons who executed the foregoing instrument, and he acknowledged to me that the same
is his free act and deed.
This instrument, consisting of ______________ () pages, including the page on which
this acknowledgment is written, has been signed on the left margin on each and every page
thereof by ___________________ and his witnesses, and sealed with my notarial seal.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal on
the day, year and place first above- written.

Doc. No. _______ Atty. ___________________________

Page No. _______ Notary Public for (place where

commissioned)

Book No. _______ Commission Serial No. _____________

Series of (year) Until Dec. 31, ____________________

Office Address ___________________
Roll of Attorney No.
PTR No.___/Issued at_____/on ______
IBP NO.__________ /date/place issued)